Acute successful management of a chainsaw injury to the roof of the left chest.

This case report chronicles the experience of prompt resuscitation, beginning with the patient, and immediate surgery following the fatal malfunction of a chainsaw. The injuries were atypical for chainsaw injuries and involved total transection of the left subclavian artery and vein, total transection of the left brachial plexus and laceration to the apex of the left lung, among other injuries. A coordinated effort allowed for successful repair of the life- and limb-threatening injuries so that the patient could return to his young family in time for his 40th birthday.

Establishing minimally invasive cardiac surgery in a low-volume mitral surgery centre.

INTRODUCTION: Despite early enthusiasm, minimally invasive cardiac surgery has had a low uptake compared with novel techniques in interventional cardiology. Steep learning curves from high-volume centres have deterred smaller units from engaging, even though low-volume centres undertake a large proportion of surgical interventions worldwide. We sought to identify the safety and experience of learning minimally invasive cardiac surgery after undertaking a structured fellowship at Blackpool Victoria Hospital, a low-volume centre. MATERIALS AND METHODS: A retrospective analysis of outcomes for all consecutive minimally invasive cardiac surgery procedures performed via a right mini-thoracotomy at our institution between 2007 and 2017 was undertaken. Clinical outcomes included death, conversion to sternotomy, stroke, renal failure and other organ support. Cardiopulmonary bypass, aortic cross-clamp times and learning cumulative sum sequential probability method curves were also assessed to determine how safely the procedure was adopted. RESULTS: A total of 316 patients were operated on for mitral, tricuspid, atrial fibrillation, septal defects or other conditions. The mean logistic European System for Cardiac Operative Risk Evaluation score was 7.0 (± 8.5). Conversion to sternotomy occurred in 12 patients (3.8%) and in-hospital mortality was 7 (2.2%). None of the converted patients died. The learning curves showed an accelerated process of adoption, similar to reference figures from a high-volume German centre. DISCUSSION: It is possible for low-volume cardiac surgical centres to undertake minimally invasive surgical programmes with good outcomes and short learning curves. Despite technical complexities, with a team approach, the learning curve can be navigated safely.

Limnological Differences in a Two-Basin Lake Help to Explain the Occurrence of Anatoxin-a, Paralytic Shellfish Poisoning Toxins, and Microcystins.

Chautauqua Lake, New York, is a two-basin lake with a deeper, cooler, and less nutrient-rich Northern Basin, and a warmer, shallower, nutrient-replete Southern Basin. The lake is populated by a complex mixture of cyanobacteria, with toxigenic strains that produce microcystins, anatoxins, and paralytic shellfish poisoning toxins (PSTs). Samples collected from 24 sites were analyzed for these three toxin classes over four years spanning 2014-2017. Concentrations of the three toxin groups varied widely both within and between years. During the study, the mean and median concentrations of microcystins, anatoxin-a, and PSTs were 91 and 4.0 µg/L, 0.62 and 0.33 µg/L, and 32 and 16 µg/L, respectively. Dihydro-anatoxin was only detected once in Chautauqua Lake, while homo-anatoxin was never detected. The Northern Basin had larger basin-wide higher biomass blooms with higher concentrations of toxins relative to the more eutrophied Southern Basin, however blooms in the North Basin were infrequent. Chlorophyll concentrations and toxins in the two basins were correlated with different sets of environmental and physical parameters, suggesting that implementing controls to reduce toxin loads may require applications focused on more than reductions in cyanobacterial bloom density (e.g., reduction of phosphorus inputs), and that lake limnological factors and morphology are important determinants in the selection of an appropriate management strategy. Chautauqua Lake is a drinking water source and is also heavily used for recreation. Drinking water from Chautauqua Lake is unlikely to be a significant source of exposure to cyanotoxins due to the location of the intakes in the deeper North Basin, where there were generally low concentrations of toxins in open water; however, toxin levels in many blooms exceeded the US Environmental Protection Agency's recreational guidelines for exposure to cyanotoxins. Current cyanotoxin monitoring in Chautauqua Lake is focused on microcystins. However, the occurrence of blooms containing neurotoxic cyanotoxins in the absence of the microcystins indicates this restricted monitoring may not be sufficient when aiming to protect against exposure to cyanotoxins. The lake has a large number of tourist visitors; thus, special care should be taken to prevent recreational exposure within this group.

Long-term survival after endoscopic vein harvest for coronary artery bypass grafting.

INTRODUCTION: Endoscopic vein harvest is the technique of choice in North America, where it constitutes 80% of conduit harvest for coronary artery bypass grafting. The UK has much lower rates, despite demonstrable perioperative benefits. Concerns about patency and long-term survival are often cited as reasons for poor uptake and evidence in the literature thus far has only addressed mid-term outcomes. We sought to identify the long-term survival of patients undergoing endoscopic vein harvest compared with a contemporaneous cohort of open vein harvest. MATERIALS AND METHODS: This was a retrospective cohort study of all consecutive patients undergoing isolated coronary artery bypass grafting at a single institution between 2007 and 2017. All-cause long-term mortality was compared using Kaplan-Meier curves and log-rank analysis. RESULTS: A total of 7,527 patients undergoing coronary artery bypass grafting (1,029 receiving endoscopic vein harvest) were studied. The groups were well matched for preoperative characteristics, except that there were more patients with triple-vessel disease and good left-ventricular function in the endoscopic vein harvest group. There was no statistically significant difference in the long-term survival (p = 0.23). At five years (median follow-up), survival was 86.1% (95% confidence interval 85.3-87.0) in the open vein harvest group compared with 85.5% (95% confidence interval 82.8-88.2) in the endoscopic vein harvest group. DISCUSSION AND CONCLUSION: Endoscopic vein harvest does not affect long-term survival in an unselected population. The contraindications for minimally invasive vein harvest in coronary artery bypass grafting are increasingly diminishing.

Preferential N-H⋯:C[double bond splayed right] hydrogen bonding involving ditopic NH-containing systems and N-heterocyclic carbenes.

Hydrogen bonding plays a critical role in maintaining order and structure in complex biological and synthetic systems. N-heterocyclic carbenes (NHCs) represent one of the most versatile tools in the synthetic chemistry toolbox, yet their potential as neutral carbon hydrogen bond acceptors remains underexplored. This report investigates this capability in a strategic manner, wherein carbene-based hydrogen bonding can be assessed by use of ditopic NH-containing molecules. N-H bonds are unique as there are three established reaction modes with carbenes: non-traditional hydrogen bonding adducts (X-H⋯:C[double bond splayed right]), salts arising from proton transfer ([H-C[double bond splayed right]]+[X]-), or amines from insertion of the carbene into the N-H bond. Yet, there are no established rules to predict product distributions or the strength of these associations. Here we seek to correlate the hydrogen bond strength of symmetric and asymmetric ditopic secondary amines with 1,3-bis(2,6-diisopropylphenyl)imidazol-2-ylidene (IPr, a representative NHC). In symmetric and asymmetric ditopic amine adducts both the solid-state (hydrogen bond lengths, NHC interior angles) and solution-state (1H Δδ of NH signals, 13C signals of carbenic carbon) can be related to the pK a of the parent amine.

Macrocycles of higher ortho-phenylenes: assembly and folding.

Higher-order structure in abiotic foldamer systems represents an important but largely unrealized goal. As one approach to this challenge, covalent assembly can be used to assemble macrocycles with foldamer subunits in well-defined spatial relationships. Such systems have previously been shown to exhibit self-sorting, new folding motifs, and dynamic stereoisomerism, yet there remain important questions about the interplay between folding and macrocyclization and the effect of structural confinement on folding behavior. Here, we explore the dynamic covalent assembly of extended ortho-phenylenes (hexamer and decamer) with rod-shaped linkers. Characteristic 1H chemical shift differences between cyclic and acyclic systems can be compared with computational conformer libraries to determine the folding states of the macrocycles. We show that the bite angle provides a measure of the fit of an o-phenylene conformer within a shape-persistent macrocycle, affecting both assembly and ultimate folding behavior. For the o-phenylene hexamer, the bite angle and conformer stability work synergistically to direct assembly toward triangular [3 + 3] macrocycles of well-folded oligomers. For the decamer, the energetic accessibility of conformers with small bite angles allows [2 + 2] macrocycles to be formed as the predominant species. In these systems, the o-phenylenes are forced into unusual folding states, preferentially adopting a backbone geometry with distinct helical blocks of opposite handedness. The results show that simple geometric restrictions can be used to direct foldamers toward increasingly complex folds.

Three Ways Isolable Carbenes Can Modulate Emission of NH-Containing Fluorophores.

Fluorescent molecules and materials that exhibit emission changes in response to analytes are of great interest across multiple disciplines. Herein, we investigate the response of NH-containing fluorophores carbazole and 2-phenylbenzimidazole (Ph-BIM) with two representative isolable singlet carbenes. Specifically, N-heterocyclic carbene 1,3-bis(2,6-diisopropylphenyl)imidazol-2-ylidene (IPr) and cyclic (alkyl)(amino)carbene (2,6-diisopropylphenyl)-4,4-diethyl-2,2-dimethyl-pyrrolidin-5-ylidene (EtCAAC) were discovered to afford three different types of reaction products with carbazole and Ph-BIM. Depending on the reaction pair, hydrogen bonding (1), NH-insertion (2,3), or proton transfer (4) products can be isolated, each displaying variable photophysical responses. These products have been structurally authenticated by single crystal X-ray diffraction and NMR spectrometric methods. Studies of the solution state behavior of 1-4 reveals that these adducts are labile and can reversibly dissociate to free carbenes and fluorophores to varying extents. These equilibria produce concentration dependent solution state behavior as identified and quantified via UV-visible absorption, emission, 1H DOSY, and NMR spectroscopic measurements.

Spatial and Temporal Variation in Paralytic Shellfish Toxin Production by Benthic Microseira (Lyngbya) wollei in a Freshwater New York Lake.

Butterfield Lake is a mesotrophic lake in New York State where residents and pets have experienced unexplained health issues. Microseira wollei (basionym Lyngbya wollei) was found at two of 15 sites in Butterfield Lake and analyzed for microcystins, anatoxins, cylindrospermopsins, and paralytic shellfish poisoning toxins (PSTs). Only PSTs and trace levels of anatoxin-a were detected in these samples. This is the first published report of PSTs within a New York State lake. To evaluate the environmental and temporal drivers leading to the observed toxicity, PST content at the two sites was examined in detail. There were distinct differences in the total PST content, filament nutrient, filament chlorophyll, and relationship to environmental drivers between the sites, as well as distinct differences in the total PST content measured using different analytical techniques. A multivariate model containing site, temperature, and filament chlorophyll explained 85% of the variation in PSTs observed over the growing season. This work emphasizes the importance of proper site selection and choice of analytical technique in the development of monitoring programs to protect lake users from the occurrence of benthic cyanobacteria toxins.

Efecto del uso preoperatorio de bevacizumab intravítreo en pacientes con retinopatía diabética proliferativa sometidos a vitrectomía- Primera actualización / Preoperative intravitreal bevacizumab for proliferative diabetic retinopathy patients undergoing vitrectomy - First update

ACTUALIZACIÓN: Este resumen Epistemonikos (Living FRISBEE: Living FRIendly Summary of the Body of Evidence using Epistemonikos) es una actualización del resumen publicado en diciembre de 2014. INTRODUCCIÓN: La retinopatía diabética proliferativa conlleva un alto riesgo de ceguera si no es tratada de manera oportuna. El tratamiento muchas veces incluye la vitrectomía. El uso preoperatorio de bevacizumab, un anti-factor de crecimiento endotelial vascular, podría mejorar variables intraoperatorias que facilitan la cirugía y mejorarían el curso postoperatorio. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cinco revisiones sistemáticas que en conjunto incluyeron 16 estudios primarios, de los cuales 14 corresponden a ensayos aleatorizados. Concluimos que el uso preoperatorio de bevacizumab disminuye la incidencia de hemorragia vítrea en el postoperatorio temprano y probablemente también en el postoperatorio tardío, pero no está claro su efecto sobre la agudeza visual. Además, probablemente disminuye el tiempo quirúrgico, podría disminuir la incidencia de roturas retinianas iatrogénicas, y si bien no está claro que disminuya la ocurrencia de sangrado intraoperatorio, podría disminuir la necesidad de uso de endodiatermia.

UPDATE: This Living FRISBEE (Living FRIendly Summary of the Body of Evidence using Epistemonikos) is an update of the summary published in December 2014. INTRODUCTION: Proliferative diabetic retinopathy can cause severe vision loss and even blindness if left untreated. Vitrectomy is often required in the treatment of more severe cases. Preoperative administration of bevacizumab, a humanized anti-vascular endothelial growth factor would improve intraoperative variables that facilitate surgery and improve postoperative course. METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified five systematic reviews including 16 studies overall, of which 14 were randomized trials. We concluded the preoperative use of intravitreal bevacizumab reduces the rate of vitreous hemorrhage in the early postoperative period, and probably also in the late postoperative period, but its effect on visual acuity is not clear. Furthermore, it probably decreases the surgical time and may decrease the incidence of iatrogenic retinal breaks. Although we are uncertain whether preoperative bevacizumab decreases intraoperative bleeding, it may reduce the need for endodiathermy.

Twist sense control in terminally functionalized ortho-phenylenes.

Many abiotic foldamers are based on achiral repeat units but adopt chiral geometries, especially helices. In these systems, there is no inherent preference for one handedness of the fold; however, it is well-established that the point chirality of substituents can be communicated to the helix. This capability represents a basic level of control over folding that is necessary for applications in molecular recognition and in the assembly of higher-order structures. The ortho-phenylenes are a structurally simple class of aromatic foldamers that fold into helices driven by arene-arene stacking interactions. Although their folding is now reasonably well-understood, access to o-phenylenes enriched in one twist sense has been limited to resolution, yielding conformationally dynamic samples that racemize over the course of minutes to hours. Here, we report a detailed structure-property study of chiral induction from o-phenylene termini using a combination of NMR spectroscopy, CD spectroscopy, and computational chemistry. We uncover mechanistic details of chiral induction and show that the same substituents can give effective twist sense control in opposite directions in mixtures of interconverting conformers; that is, they are "ambidextrous". This behavior should be general and can be rationalized using a simple model based on sterics, noting that arene-arene stacking is, to a first approximation, unaffected by flipping either partner. We demonstrate control over this mechanism by showing that chiral groups can be chosen such that they both favor one orientation and provide effective chiral induction.

Linker-Directed Assembly of Twisted ortho-Phenylene-Based Macrocycles.

o-Phenylene tetramers have been coassembled with linkers into macrocycles through imine condensation. Variation of linker connectivity and length allows both [1 + 1] and [2 + 2] macrocycles to be obtained, complementing (previously reported) [3 + 3] macrocycles. For the [1 + 1] macrocycles, linker length has a clear effect on o-phenylene geometry and macrocycle stability. For the [2 + 2] macrocycles, both homo- and heterochiral configurations are observed, suggesting limited communication of helix handedness in these systems.

Twisted Macrocycles with Folded ortho-Phenylene Subunits.

Many foldamers, oligomers that adopt well-defined secondary structures, are now known, including many exhibiting functional behavior. However, examples of foldamer subunits within larger architectures remain rare, despite the importance of higher-order structure in biomacromolecules. Here, we investigate the dynamic covalent assembly of short o-phenylenes, a simple class of aromatic foldamers, into twisted macrocycles. o-Phenylene tetramers have been combined with rod-shaped p-phenylene-, tolane-, and diphenylbutadiyene-based linkers using imine formation. Macrocyclization proceeds efficiently, inducing folding of the o-phenylenes. The resulting [3 + 3] macrocycles (three o-phenylenes and three linkers) are shape-persistent, triangular structures with twisted cores and internal diameters up to approximately 2 nm. The homochiral D3-symmetric and heterochiral C2-symmetric conformers can be distinguished by NMR spectroscopy. Analysis of the conformational distribution for the p-phenylene-linked macrocycle suggests that the o-phenylene units are largely decoupled, with the less-symmetrical configuration therefore entropically favored. Conformational dynamics were assessed by variable-temperature NMR spectroscopy. Confinement within the macrocyclic architecture slows the inversion of the o-phenylene moieties.

A two-center comparative study of gastric pull-up and jejunal interposition for long gap esophageal atresia.

PURPOSE: When restoration of the anatomical continuity in case of long gap esophageal atresia (LGEA) is not feasible, esophageal replacement surgery becomes mandatory. The aim of this paper is to critically compare the experience of two tertiary referral centers in The Netherlands performing either gastric pull-up (GPU) or jejunal interposition (JI). METHODS: Retrospective chart review of all the patients with LGEA who underwent GPU in the University Medical Center Groningen and JI in the University Medical Center Utrecht. Main endpoints were short term morbidity, mortality and long term functional outcome (digestive functioning and growth). Descriptive analyses conducted using Mann-Whitney U test for continuous variables and Fisher's exact test for categorical variables. RESULTS: Nine children underwent GPU and 15 JI. Median age (years) at last follow up was fourteen (GPU) and eight (JI). One patient died, 10 years after JI. No grafts were lost. Perioperative anastomotic complications were reported more often after JI (73% vs. 22%, p=0.03). However reintervention rate was the same in both groups (33%). Among long term outcomes, functional obstruction was not registered after GPU, while it was recorded in 46% after JI (p=0.02). No other significant differences were found apart from some tendencies concerning full oral nutrition and gastroesophageal reflux (GPU>JI). CONCLUSION: Comparative data from this study reveal no mortality but significant morbidity in both groups. No graft was lost. Although not statistically different as a result of small patient numbers, clinically important differences regarding gastrointestinal system were noted. Growth should be monitored closely in both groups.

Tetrabenzanthanthrenes by mitigation of rearrangements in the planarization of ortho-phenylene hexamers.

In general, ortho-phenylene hexamers are not good substrates for oxidative planarization because of competing backbone rearrangements. However, by first planarizing the ends, a target tetrabenzanthanthrene has been obtained by oxidation in good yield. DFT calculations suggest that the larger polycyclic aromatic subunits of the preplanarized substrate increase the rate of planarization relative to that of rearrangement. By implication, it may be possible to prepare graphene structures that cannot be made directly from simple polyphenylenes by instead designing precursors with larger polycyclic aromatic moieties. The photophysical properties of the tetrabenzanthanthrene core indicate that it may have promise as a functional chromophore.

[Interdisciplinary and individualized therapy of prostate cancer : International prostate cancer symposium Bonn 2013 - challenges and targets]. / Interdisziplinäre und individualisierte Therapie des Prostatakarzinoms : Internationales Prostatakrebssymposium Bonn 2013 - Herausforderungen und Ziele.

Multimodal treatment of prostate cancer is based on specific staging via imaging, clinical parameters, tumor markers and histopathological grading. Risk-adapted therapy encompasses wait and see, active surveillance, surgical intervention, radiotherapy and hormone therapy. Some patients also need a combination of these treatment options. Even though clinical parameters guide the treatment plan, patient wishes and preferences are incorporated. Against this background leading basic research scientists, urologists, radiotherapists, epidemiologists and members of other associated disciplines discussed state of the art treatment concepts, innovative trial designs and translational research projects at the international meeting "Challenges and Chances in Prostate Cancer Research" organized by the German Cancer Aid (Deutsche Krebshilfe).

Thoracotomy versus VATS: is there an optimal approach to treating pneumothorax?

INTRODUCTION: The 2010 British Thoracic Society guidelines recommend that a weighted decision be made by clinicians with regard to surgical intervention for pneumothorax as the video assisted thoracoscopic surgery (VATS) approach is better tolerated by patients but carries a higher rate of recurrence (5% vs 1%). METHODS: Overall, 163 patients underwent surgical intervention for pneumothorax at our institution and data were collected prospectively for almost 7 years. Of these, 86 patients underwent VATS under a single surgeon with extensive VATS experience to compensate for the associated learning curve while 79 patients underwent an open procedure. RESULTS: There was no statistically significant difference in the recurrence rate between the open and the VATS group (1% vs 3.5%, p=1.0). The VATS group was superior to the open group in terms of reduced postoperative bleeding (7.5% vs 0%, p=0.01), reduced number of intensive care unit admissions (16% vs 0%, p<0.01) and a reduced adjusted length of stay (3 vs 5.5 days, p<0.01). CONCLUSIONS: A comparable recurrence rate is attainable with a VATS approach once the learning curve is surpassed and a reduction in morbidity is an additional merit.

Interdependence of Genotype and Growing Site on Seed Mineral Compositions in Common Bean.

Essential minerals are considered as key determinants of optimum health and nutritive quality of common bean seed. This study aimed to identify genetically stable essential minerals in common bean. Eleven diverse common bean genotypes were grown in three distinct growing environments and 17 essential minerals were analyzed by Inductively Coupled Plasma-Optical Emission Spectroscopy. Genetic control of mineral composition in common bean seed was demonstrated by large (p<0.01) genotypic differences in Ca and Sr contents and moderate genotypic difference was observed in Fe content. Significant influence of genotype and environments (G×E) interaction was observed in the content of all minerals. The ratios between genetic and environmental variances and between genetic and G×E variances indicated the greater influence and stability of genetic factor on the concentration of Ca and Sr in common bean seed. Significant positive correlations among important minerals such as Zn with S, P, Fe and Na and Cu with K, Mg, Ni, P were identified. The stability of genetic effects on Ca and Sr concentration in common bean has been identified in this study. Calcium is one of the most important minerals which regulates many cellular processes and has important structural roles in living organisms. Further studies to characterize Ca physiology in common bean may identify genetic or biochemical markers to expedite breeding common bean with enhanced Ca concentration.

What is the impact of endoscopic vein harvesting on clinical outcomes following coronary artery bypass graft surgery?

Objective Endoscopic vein harvesting (EVH) is increasingly used as an alternative to open vein harvesting (OVH) for coronary artery bypass graft (CABG) surgery. Concerns about the safety of EVH with regard to midterm clinical outcomes following CABG have been raised. The objective of this study was to assess the impact of EVH on short-term and midterm clinical outcomes following CABG. Design This was a retrospective analysis of prospectively collected multi-centre data. A propensity score was developed for EVH and used to match patients who underwent EVH to those who underwent OVH. Setting Blackpool Victoria Hospital, Plymouth Derriford Hospital and the University Hospital of South Manchester were the main study settings. Patients There were 4709 consecutive patients who underwent isolated CABG using EVH or OVH between January 2008 and July 2010. Main outcome measures The main outcome measure was a combined end point of death, repeat revascularisation or myocardial infarction. Secondary outcome measures included in-hospital morbidity, in-hospital mortality and midterm mortality. Results Compared to OVH, EVH was not associated with an increased risk of the main outcome measure at a median follow-up of 22 months (HR 1.15; 95% CI 0.76 to 1.74). EVH was also not associated with an increased risk of in-hospital morbidity, in-hospital mortality (0.9% vs 1.1%, p=0.71) or midterm mortality (HR 1.04; 95% CI 0.65 to 1.66). Conclusions This multi-centre study demonstrates that at a median follow-up of 22 months, EVH was not associated with adverse short-term or midterm clinical outcomes. However, before the safety of EVH can be clearly determined, further analyses of long-term clinical outcomes are required.

Biliary atresia in the Netherlands: outcome of patients diagnosed between 1987 and 2008.

OBJECTIVE: To examine the outcome of biliary atresia (BA) and to identify prognostic factors using a national database. STUDY DESIGN: All children born between January 1987 and December 2008 who underwent the Kasai surgical procedure for BA were retrieved from the Netherlands Study Group on Biliary Atresia Registry database. Outcomes were measured in terms of clearance of jaundice (bilirubin <1.17 g/dL, or 20 µmol/L, within 6 months after surgery) and 4-year transplant-free survival. Two cohorts, one from 1987-1997 and the other from 1998-2008, were compared. Survival rates were determined using Kaplan-Meier analysis, and prognostic factors were tested with univariate and multivariate analyses. RESULTS: Between January 1987 and December 2008, 214 patients underwent Kasai surgery for BA. In this series, the 4-year transplant-free survival was 46%±4%, and 4-year overall survival was 73%±3%. Clearance of jaundice, surgery within 60 days, and postoperative antibiotic prophylaxis use were independently associated with increased transplant-free survival. The yearly caseload per center (range, 0.5-2.1) was not correlated with transplant-free survival (r=0.024; P=.73). CONCLUSION: During the past 2 decades, outcome parameters have remained constant and are comparable with those reported from other Western countries, despite a relatively low annual caseload per center. Timely surgical correction and postoperative antibiotic therapy were associated with a higher transplant-free survival rate.

Mortality of biliary atresia in children not undergoing liver transplantation in the Netherlands.

In order to further improve the outcome of BA, we characterized the mortality of BA patients who did not undergo OLT in the Netherlands, and compared our results with international data. For this purpose, we analyzed the causes of mortality of non-transplanted BA patients before the age of five yr, using the NeSBAR database. To evaluate trends in mortality, we compared the cohort 1987-1996 (n=99) with 1997-2008 (n=111). We compared clinical condition at OLT assessment with available international data, using the PELD-score. Mortality of non-transplanted BA children was 26% (26/99) in 1987-1996 and 16% (18/111) in 1997-2008 (p=0.09). Sepsis was the prevailing direct cause of death (30%; 13/44). PELD-scores at the time of assessment were higher in non-transplanted BA patients (median 20.5; range 13-40) compared with international data (mean/median between 11.7 and 13.3). Based on our national data, we conclude that pretransplant mortality of BA patients is still considerable, and that sepsis is a predominant contributor. Our results strongly indicate that the prognosis of patients with BA in the Netherlands can be improved by earlier listing of patients for OLT and by improving pretransplant care.